Vinnytsa National Pirogov memorial Medical University
It is ratified
at the conference of Department of Surgery #1 Medical Faculty #1/ Chief of Department
professor______V.A. Shaprinskiy
“______” ______20
THE MANNUAL
FOR INDIVIDUAL WORK OF STUDENTS
AT THE TRAINING BEFORE LESSON
Educational discipline / SurgeryModule / 2
Topic of the lesson / Obstructive jaundice. Reasons. Differentially diagnostic, tactic. The modern methods of treatment. Hepatic insufficiency at surgical illnesses, methods of prophylaxis and treatment.
Year / VI
Faculty / Medical №1
1. Background: obstructive jaundice is one of the most difficult running across diseases of the gastrointestinal tract and the most common of all types of jaundice. Important role in choosing the correct treatment strategy belongs to the differential diagnosis of jaundice, and the effects of surgical treatment depends on the correct surgical treatment.
2. The specific objectives.
To know:
1. The anatomic features of the abdomen;
2. The anatomical structure of the liver, and syntopy skeletopy;
3. Surgical anatomy of the bile ducts;
4. Methods of diagnosis of obstructive jaundice;
5. The differential diagnosis of obstructive jaundice with other types of jaundice;
6. Indications and types of surgery for obstructive jaundice;
7. Postoperative complications and their prevention.
Be able to:
1. Analyze data evaluate the patient data and objective examination of the correct diagnosis;
2. Analyze data of laboratory methods of examination;
3. Analyze data radiographic examination methods, ultrasound, ECG, FEHDS;
4. Determine the nature of the jaundice and to the differential diagnosis of obstructive jaundice;
5. To be able to choose the right tactics of conservative and surgical treatment.
3. Interdisciplinary integration:
1. / Anatomy
Physiology / The structure of the liver and anatomical features of its location in the abdomen
Features hepatobiliary function / To determine the organ or system damage, especially the segmental structure of the liver, liver blood supply and innervation.
Assess the state and condition of the patient gemodynamics of blood based on functional performance. To substantiate the clinical and physical symptoms.
2. / Gastroenterology. Infectious diseases. Intensive care and resuscitation.
Radiology. Functional diagnostics. / Types of jaundice, clinical symptoms, objectively details, laboratory and instrumental methods of examination, radiological signs of obstructive jaundice. / Conduct survey of patients with jaundice. Differential diagnosis jaundice. The diagnostic and therapeutic management of obstructive jaundice.
3. / Internally subject Integration: hepatic failure, bleeding, respiratory failure
Surgery and postoperative period. / Signs of liver failure and bleeding, hemostatic drugs used to stop bleeding.
Signs of respiratory and cardiovascular, hepatic insufficiency. / Suspected signs of obstructive jaundice and liver failure, jaundice hold differential diagnosis to determine current therapeutic approach to the prevention of complications.
4. Basic knowledge, skills necessary for studying the topic.
The theoretical questions to the studies:
• Definition, etiology, pathogenesis OJ;
• Classification, complications OJ;
• Clinic OJ depending on the stage and course options;
• Differential diagnosis of OJ with other types of jaundice;
• Principles of conservative treatment OJ;
• Systemic and regional antimicrobial treatment in OJ;
• Detoxification, anti-inflammatory, desensitizing therapy in OJ;
• Indications and contraindications for radical surgery in OJ volumes and interventions;
• Features the treatment of patients with OJ;
• Rehabilitation and clinical monitoring of patients after undergoing OJ.
• Types of drainage systems.
Practical tasks are performed in class:
• A clinical examination of the patient with OJ;
• Identify the most characteristic clinical signs OJ.
• The Plan examination of the patient.
• Interpretation of laboratory and instrumental investigations.
• Formulation of diagnosis
• Writing assignments topical medication the patient
• Identify indications for surgical treatment, the choice of its volume
5. Contents subject classes: obstructive jaundice (OJ) - is a type of jaundice caused by the impaired patency of the biliary tract, due to their obstruction inside or external compression by tumor, uterine, or another process. The most common cause of biliary tract obstruction is calculus. The incidence of jaundice on the basis of bile duct obstruction ranges from 30 to 85%. This choledocholithiasis occurs in women more often.
Etiology and pathogenesis
Obliteration of external biliary ducts can arise due to various causes: as a result of inflammatory process of surrounding organs (pancreas, paracholedochus lymph nodes), damage of walls of ducts during operations. However, in most cases it is a gallstone disease, choledocholithiasis and related to them, scars of large papilla of duodenum. The second cause of obstructive jaundice is due to tumours of the cancer of head of pancreas and large papilla of duodenum.
Disregarding the fact that each of the adopted diseases has special clinical features, obstruction of biliary ducts causes the changes which have general character. With complete blockade of external biliary ducts and increase of pressure higher than 300 mm of waters or 2,94 kPa (after a norm - not higher 150 mm or 1,47 kPa), excretions of bile into biliary capillaries is stopped. It is characterized by the fact that the secretory mechanism of hepatic cells (hepatocyte) can not overcome such resistance.
Thus bile enters into the lymphatic vessels and vein of liver and from there enters blood, causing the syndrome of mechanical jaundice.
Classification (by O.O. Shalitnov, 1993).
Obstructive jaundicees is divided into:
I. According to the level of barrier:
1) obstruction of distal parts of common bile duct;
2) obstruction of supraduodenal part of common bile duct;
3) obstruction of initial part of general hepatic duct and fork of hepatic ducts.
II. According to the etiologic factor:
1) characterized obstruction by calculus, foreign bodies, grume of blood during hemobilia, parasites, iatrogenic influence during operation;
2) obstruction due to diseases of the wall of biliary tract — innate anomalies (hypoplasia, cysts and atresia), inflammatory diseases (obstructing papillitis and cholangitis), scar strictures (posttraumatic and inflammatory), biliary tract tumours;
3) obstruction caused by diseases of other organs lying near the biliary tract, that pull them into the process (tubular stenosis of common bile duct of pancreatic origin, ulcer disease of duodenum, paracholedocheal lymphadenitis, adhesions).
Except that, according to the duration the disease is distinguished into:
1) acute obstructive jaundice, which last for 10 days;
2) prolonged, that last from 10 to 30 days;
3) chronic, that last for more than a month.
Clinical management.
The clinical picture of obstructive jaundice is mainly due to the violation of outflow of bile.
The pain syndrome is a characteristic accompaniment of gallstone disease and choledocholithiasis, that appears with the attacks of hepatic colic. However, pain syndrome in these pathologies is not often expressed or is usually absent. Pain is often observed in stricture of biliary ducts, but it is not quite typical of patients with the cancer of bile ducts.
Icterus is an important sign of obstruction of biliary tract, speed of origin and intensity of which depend on the amount of passage of bile into the intestine.
The itching of body is a frequent accomponiment of icterus, that arises up as a result of action of biliary acids. During examination the yellowness of sclera, mucosa and skin are observed. At the same time patients complains of high colored urine and discolorations of stools darkening ("argil"). The increase of temperature of body testifies the development of cholangitis, metastasis of tumors in liver is rarer.
In the right hypochondrium in emaciated patients it is sometimes possible to see a mass, that moves during breathing, probably it is the gall-bladder. If it is elastic, is not painful and it is accompanied by icterus (the Courvoisier's symptom), patient is then having cancer of head of pancreas or distal parts of common bile ducts.
Laboratory analysis.
For obstructive jaundice a cholestatic syndrome with high bilirubinemia mainly due to direct faction of bilirubin and bi-lirubinuria is characteristic, by absence of urobilin in urine and stercobilin in fecus, by high activity of alkaline phosphatase at the insignificantly promoted transaminase activity and negative thymol test.
With increase of hyperbilirubinemia this intercommunication changes to the side of increase of direct bilirubin. In general analysis of blood unsteady changes are which depend on the degree of intoxication or occult bleeding (in cancer patients).
Sonography examination allows to define the sizes of liver, gallbladder, state of internal and external hepatic ducts, presence and degree of dilatation or narrowing, presence or absence of calculus and new formation in hepatic parenchyma (fig. 3.4.29).
Duodenography in the conditions of artificial low blood pressure apply for the exposure of pathology of organs of pancreatoduodenal area.
Retrograde cholangiopancreatography enables to examine stomach, duodenum by endoscope, to conduct biopsy, to extract bile and pancreatic juice for examination, to get the roentgenologic image of ducts: external and internal hepatic ducts and duct of pancreas, and in a number of cases in the presence of calculus to conduct endoscopic papillotomy and extraction calculus through papillotomic access.
Percutaneous transhepatic cho-langioduodenography is used for the exposure of pathology of biliary tract. It to certain extent allows to expose both character and location of obstruction in the hepatoduodenal area (fig. 3.4.31).
Laparoscopy is a diagnostic remedy that enables to define the sizes of liver, its colour, character of surface, presence of metastases, size and degree of tension of gall-bladder. Under the control laparoscope it is possible to execute puncture of gall-bladder and conduct cholecystocholangiography and cholecystostomy.
The scanning of liver creates terms in which it is possible to expose the primary and metastatic tumours of liver or other pathology of organ.
Clinical variants and complicationss
Clinical features of obstructive jaundice almost always depends on the causes of obstruction of biliary duct. In patients with tumours icterus gradually progresses and is seen in complete and permanent obstruction, along with that, in presence of calculus in biliary ducts intensity of icterus can vary. Its temporal, transitional character takes place in choledo-cholithiasis, acute cholecystitis or pancreatitis.
On this background, cholangitis, togather with abscess formation in liver, sepsis develops. In other case there can be the bleeding (more frequent gastroduodenal) or hepato-renal insufficiency.
In some patients internal biliary fistula, which clinically is a proof of cholangitis, appears as a result of inflammatory and necrotic processes. On the skiagram survey of organs of abdominal cavity in such cases it is possible to see air in the hepatic ducts, the so called "aerocholia".
Diagnosis programme
1. History and physical methods of examination.
2. General analysis of blood and urine.
3. Analysis of urine on diastasis.
4. Biochemical blood test (bilirubin, urea, albumin-globulin coefficient, blood on an australian antigen, amylase, alanine aminotransferase, asparaginase, alkaline phosphatase).
5. Coagulogram.
6. Sonography.
7. Endoscopy.
8. Retrograde cholangiopancreatography.
9. Laparoscopy with biopsy.
10. Percutaneous transhepatic cholangioduodenography.
11. Computer tomography.
Differential diagnosis
The main task of differential diagnosis of jaundice is to determine whether it is surgical or nonsurgical nature. It is always advisible to remember, that among the diseases which can present as jaundice, viral hepatitis takes a considerable place, mostly its cholestatic form, new formation of hepatopancreatoduodenal area and gallstone disease.
Viral hepatitis is one of many clinical forms of viral infection the characteristic feature of which is prolonged cholestasis. The disease carries the prolonged character. For the pre-icteric period of hepatitis the inherent clinical triad is the itching of skin, fever and arthralgia. Approximately in half of patients it is possible to palpate the spleen and moderately increased liver. Laboratory finding show the increase of activity of alanine aminotransferase and aspartate aminotransferase and positive thymol test. Also the reaction of biliary pigments, biliary acids and urobilin in urine is positive.
Difficulty in the verification of diagnosis it is necessary to take into account of such diseases, as viral hepatitis in patients with cholelithiasis or obstruction by tumour in patients who suffer from alcoholism.
Taking into account information by history together with the results of sonography, endoscopic retrograde pancreatocholangiography or percutaneous transhepatic cholangioduodenography and laparoscopy, one can come to diagnosis. Thus in the first stage it is needed to use the noninvasive methods of diagnosis (sonography), secondly - invasive methods of the direct contrast of biliary tract (retrograde endoscopic cholangiopancreatography, percutaneous transhepatic cholangiopancreatography) are useful.
Techniques and choice of treatment method.
Final diagnosis, that maximally represents the character of obstructive jaundice, as a rule, is set only during the intraoperative revision of the organs. In determination of medical techniques and choice of method of surgical treatment of such jaundice it is needed also to objectively estimate severity and general condition of patients. For this purpose it is necessary to take into account the character of icterus, stage of hepatic insufficiency keeping in mind the duration and intensity of cholestasis, presence and character of cholangitis, severity and expression of accompanying pathology.
Medical measures in preoperative period must be directed in correction of violations of homeostasis, hemocoagulation (aminocapronic acid, vicasol, 10% solution of chlorous calcium, fresh-frozen plasma, inhibitor of protease), improvement of microcirculation in liver (10% solution of glucose with insulin, reopolyhlucine, hepatoprotectors), desintoxication organism (neohemodes, enterosorbent), biliary decompression (percutaneous transhepatic cholangiostomy or cholecystostomy), antibacterial therapy for cholangitis taking into account the character of microflora and its sensitiveness to the antibiotics and vitamins.
In case of the gallstone disease complicated by choledocholithiasis and mechanical icterus, the volume of surgical interference must include: cholecystectomy, choledocholithotomy and external or internal drainage of common bile duct. In presence of the special apparatus in case of choledocholithiasis complicated by mechanical icterus, two-stage tactics of treatment is the method of choice - endoscopic papillosphincterotomy with subsequent extraction of calculus and their lithotripsy on the first stage and cholecystectomy - on the second. Endoscopic papillosphincterotomy is the method of choice for treatment of remaining (after cholecystectomy) choledocholithiasis.
For older patients with severe pathology combination of extracorporal shock-wave lithotripsy with endoscopic sanitation of hepaticocholedochus is an effective method. For some of them with high risk of operative treatment and small calculus of common bile duct (by the diameter of to 10 mm) endoscopic papillotomy can be effective.